PREVALENCE OF DRUG INDUCED HEPATIC INJURY IN PATIENTS
TREATED FOR CO-INFECTIONS OF TUBERCULOSIS AND HUMAN
IMMUNODEFICIENCY VIRUS IN AYDER REFERRAL HOSPITAL ART
CLINIC, MEKELLE-ETHIOPIA
Minyahil A. Woldu 1*, Addishiwot G. Zewde 2 and Jimma L. Lenjissa1
1
Ambo University, Department of Pharmacy, College of Medicine and Health Sciences, Ambo,
Ethiopia
2
Mekelle University, Department of Pharmacy, College of Health Sciences, Mekelle, Ethiopia
Corresponding Author*
Department of Pharmacy
College of medicine and health Sciences,
Ambo University,
P.O.Box: 19
E-mail: minwoldu@gmail.com
Tel. (Mobile): +251912648527
Ambo, Ethiopia.
1|Page
ABSTRACT
Background: Concomitant use of treatment for tuberculosis and antiretroviral therapy is
complicated by the adherence challenge of polypharmacy and overlapping side effect like druginduced hepatotoxicity.
Objective: To determine the prevalence of hepatotoxicity in patients treated for the co-infections
of TB/HIV using serum ALT levels as marker of hepatotoxicity.
Result: The most frequent type of hepatotoxicity grade observed was toxicity degree type one,
which was observed in 45% of the patients. Five percent of female and 10% male on HAART
and anti-TB medications developed hepatotoxicity. Patient in age between 19-62 year were
develop almost double the prevalence i.e 10%, compared to 4% in </=18 year and only 1% in
age >/=63 year. The prevalence of severe hepatotoxicity (grade 2 or more) was 15 (15%). There
was no significant correlation in toxicity grade at baseline ALT measures, (Spearman Correlation
Asymp. Sig. (2-sided) = .878). However, the ALT measure after three month showed that
significant association with the grades of toxicity, (Spearman Correlation Asymp. Sig. (2-sided)
= .000). HCV infection was significantly associated with the risk of hepatotoxicity, which
occurred in 3 out of 4 of the study participants (OR, 22.7; P.value, 0.34).
Conclusion: The prevalence of hepatotoxcity in the study area was comparable to other similar
studies. HBV co-infection was an independent risk factor for hepatotoxicity. Clinicians must
consider the possibility of drug-induced liver injury in the management of HIV-infected patients,
especially in those with certain risk factors such as co-infection with hepatitis B virus (HBV).
Key words: Drug induced hepatic injury, TB/HIV co-infections, Heptotoxicity, Prevalence of
drug induced hepatic injury
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INTRODUCTION
Worldwide, it is estimated that 14.8% of all new tuberculosis (TB) cases in adults are attributable
to human immunodeficiency virus (HIV) infection. This proportion is much greater in Africa,
where 79% of all TB/HIV co infections are found. In 2007, 456 000 people globally died of
HIV-associated TB (1). The advent of highly active antiretroviral therapy (HAART) in the
treatment of HIV infection has significantly decreased the incidence of opportunistic infections
as well as improved morbidity and mortality among HIV patients (2). However, along with these
positive outcomes, HAART is associated with a host of adverse reactions such as hepatotoxicity,
hyperlipidemia, hyperglycemia, and lactic acidosis (3).
TB is the most common opportunistic infection among people with HIV infection and their coinfection poses many problems with regard to diagnosis, treatment, drug resistance, adverse drug
reaction, mortality and burdens on the health systems. Concomitant use of treatment for
tuberculosis and antiretroviral therapy is complicated by the adherence challenge of
polypharmacy and overlapping side effect profiles of antituberculosis (anti-TB) drugs and
antiretroviral drugs. Drug-induced hepatotoxicity (DIH) is one of the overlapping side effects of
both antiretroviral therapy (ART) and first line anti-TB drugs leading to interruption of
treatment(2, 4-7). The major cause for these are: additive toxicity of the anti-TB and ART
medications, overlapping hepatitis C (HCV) and hepatitis B virus (HBV) infections, and other
co-administered medications like cotrimoxazole and anti-fungals, as well as alcohol abuse (8, 9).
When Hepatotoxicity occur the liver shows an elevation in serum Aaspartate aminotransferase
(AST) or Alanine aminotransferase (ALT) level from the normal range (AST = 0-37 and ALT<
41 IU/l ) to >3x upper limit of normal in the presence of symptoms, or Serum AST or ALT >5x
upper limit of normal in the absence of symptoms (1, 10, 11) . AST/ALT elevations instead of
alkaline phosphatase (ALP) elevations favor liver cell necrosis as a mechanism over cholestasis.
When AST and ALT are both over 1000 IU/L, the differential can include acetaminophen
toxicity, shock, or fulminant liver failure. When AST and ALT are >3X of normal but not >
1000 IU/L, the differential can include alcohol toxicity, viral hepatitis, drug induced, liver
cancer, sepsis, Wilson disease, post-transplant rejection of liver, autoimmune hepatitis, and
steatohepatitis (non-alcoholic). When AST/ALT elevated are minor it may be due to
rhabdomyolysis among many possibilities (12). Therefore, these tests could be used as markers
of hepatocellular injury (13). Hepatocellular injury has different grading scale from mild to
severe based on the laboratory value of the ALT or AST (14, 15). Studies have revealed that 1420 % of adults on ART had elevated serum liver enzymes as a marker of hepatocellular injury
(16).
Liver enzyme elevations (LEEs) have been described in association with all major classes of
antiretroviral therapy (ART)(4) and anti-TB drugs including isoniazid, rifampicin, pyrazinamide
and ethambutol. Among the four anti-TB drugs, isoniazid, rifampicin, and pyrazinamide play
major role in causing hepatotoxicity (17). However, the complexity of medication used in both
ART and anti-TB complicates the understanding of the independent effects of each drug in the
development of drug induced liver injury (4). Hepatotoxicity is the major problem associated
with TB/HIV co infection. Thus, the purpose of this study was to determine the prevalence of
hepatotoxicity in patients treated for TB-HIV co infection using the serum ALT level as marker
of hepatotoxicity.
3|Page
METHODS
Study area
The study was conducted in Ayder referral hospital of Tigray regional state, Northern Ethiopia,
786 km away from the capital city of Ethiopia, Addis Ababa.
Study design
A case-control study was conducted. ‘Cases’ were those who develop change in their laboratory
value for liver function tests with increment in ALT level from the baseline standards, while
‘controls’ were those who did not change their laboratory value for liver function tests of ALT
measurements.
Sample size determination
The formula for calculating sample sizes
Where,
 p is the Prevalence rate assumed in undiseased (control) groups global studies (14-20%)
(7). So, p = 0.2 0r 20% has been taken for this study.
 K is 1 (control : case ratio = 3 :1)
 R is the odds ratio Odds to be detected (R = 5)
 α=0.05 (two-tailed)
 β = 0.20 (power = 80%)
 Z1-α is the standard normal value at 95% confidence interval (±1.96)
 Z1-β is the Z value corresponding to the power of 80% (0.842)
Substituting all the values, N becomes 25 (i.e. Triple this number would be included in the
control group).
Data collection instrument
A prepared and pretested checklist was used to collect data from the patient charts and files.
Socio-demographic, ART treatment regimen, other co-morbidities and laboratory values for liver
function tests were components of the checklist.
4|Page
Data organization and analysis
Data was compiled, processed, and analyzed using Statistical Package for Social Sciences
(SPSS) for windows version 16. Descriptive statistics was used to summarize data and statistical
analysis using logistic regression was carried out to determine whether there was any association
between the dependent and independent variables. A 95% CI and p-value of <0.05 was
considered to be statistically significant.
Ethical consideration
A formal permission letter was secured from Mekelle University prior to obtaining any
information from patients’ medical records and charts.
Operational definitions
The following WHO operational definitions were used in the study:
Toxicity of degree 0: the level of toxicity which is considered as normal in which its
value is <1.25 x normal value of ALT in serum
Toxicity of degree 1: the Level of toxicity which is considered as weak in which its
value is 1.256 – 2.5 x normal value of ALT in serum
Toxicity of degree 2: the Level of toxicity which is considered as moderate in which its
value is 2.6 – 5 x normal value of ALT in serum
Toxicity of degree 3: the Level of toxicity which is considered as severe in which its
value is 5.1 – 10 x normal value of ALT in serum
Toxicity of degree 4: the Level of toxicity which is considered as severe in which its
value is >10 x normal value of ALT in serum
Category I anti-Tb drugs: Initial Phase (8 weeks) with INH, RIF, PZA, EMB and
Continuation Phase (26 weeks) with INH/RIF or INH/RPT
Category II anti-Tb drugs: Initial Phase (8 weeks) with INH, RIF, PZA, EMB and
Continuation Phase (26 weeks)with INH/RIF or INH/RPT
Category III anti-Tb drugs: Initial Phase (8 weeks) with INH, RIF, PZA, EMB and
Continuation Phase (26 weeks) with INH/RIF
Category IV anti-Tb drugs: Initial Phase (8 weeks) with INH, RIF, EMB and
Continuation Phase (39 weeks) with INH/RIF
5|Page
RESULT
Background characteristics of the study subjects
In this study, 100 patient records were sampled and studied. The mean age of the study subjects
was 33.6 + 17 years. The age range was between 4 and 70. More than half of the study subjects
55 (55 %) were females. The most frequent type of TB diagnosed was extra-pulmonary TB
(59%) while category one anti-TB regimen was used almost in 85% of the study participants.
Sixty two percent of the patients were on WHO HIV stage four and in 94% of the participants
ART regiment containing NRTI + NNRTI was used. Only 4% of the patients were positive for
hepatitis B surface antigen (HBsAg) test while 79% of them were on cotrimoxazole (CTM)
prophylaxis (Table 1).
Characteristics of liver function test (ALT test)
The most frequent type of hepatotoxicity grade observed was toxicity degree type
one, which was observed in 45% of the patients. No hepatotoxicity was observed
in 40% of the study participants while only 7% were developed toxicity degree
type three, which could result in regimen change, discontinuation or drug
desensitization, if it is symptomatic (Fig.1).
Determinants of heptotoxicity
Five percent of female and 10% male on HAART and anti-TB medications developed
hepatotoxicity. Patient in age between 19-62 year were develop almost double the prevalence i.e
10%, compared to 4% in </=18 year and only 1% in age >/=63 year respectively (Table 2). This
result may be comparable to the number of participants involved in the study. When we compare
the prevalence of hepatotoxicity based on the WHO stage of HIV classification, 11% percent of
the patients who develop hepatotoxity were found in stage IV. Fourteen percent of patient
develop hepatotoxicity were also on ART combination of NRTIs and NNRTIs. From anti-TB
medication category majority i.e 12% were on category one anti-Tb medications.
6|Page
Table 1: The background characteristics of patients on anti-TB and HAART medications,
Ayder referral hospital, Mekelle-Ethiopia; 2013.
Variables
age category
Sex
TB infection
Anti-Tb drug
regimen
WHO staging
ART regimen
HBV
Co-trimoxazole
prophylaxis
7|Page
Frequency
Percent
</=18
18
18.0
19-62
69
69.0
>/=63
13
13.0
Female
55
55.0
Male
45
45.0
Pulmonary TB
41
41.0
Extra-pulmonary Tb
59
59.0
Category one
85
85.0
Category two
11
11.0
Category there
4
4.0
Stage one
2
2.0
Stage two
1
1.0
Stage there
35
35.0
Stage four
62
62.0
NRTI + NNRTI
94
94.0
NRTI + PI
5
5.0
NRTI + NRTI
1
1.0
Positive
4
4.0
Negative
96
96.0
Yes
79
79.0
No
21
21.0
Figure 1: Grade of toxicity based on ALT test result of patient on co-medication for HIV/TB
infections, Ayder referral hospital, Mekelle-Ethiopia; 2013.
8|Page
Table 2: Mean, frequency and standard deviation of ALT, based on degree of toxicity of patients
on anti-TB and HAART medications. Ayder referral hospital, Mekelle-Ethiopia; 2013.
Toxicity of degree-ALT
0
Mean
N
Std. Deviation
1
Mean
N
Std. Deviation
2
Mean
N
Std. Deviation
3
Mean
N
Std. Deviation
Total
Mean
N
Std. Deviation
9|Page
ALT baseline
ALT after
33.45
38.30
40
40
17.840
21.042
36.87
68.64
45
45
20.141
45.491
45.12
161.00
8
8
29.479
95.367
26.14
142.43
7
7
16.446
95.446
35.41
69.06
100
100
19.993
61.118
DISCUSSION
According to the WHO category of HIV stages, the majority of our study participants 62 (62%)
were in stage four (Table 1). In other study the majority were in stage III (71.4%) (4). The
toxicity grade observed in our study had similar pattern with previously conducted studies (4).
A number of studies reported that the rates of severe hepatotoxicity in TB/HIV co-infected
patients receiving both NNRTI based ART and rifampin containing anti-TB drugs concurrently
range from 0.6% to 13% (18, 19). In our study the rate of severe hepatotoxicity (grade 2 or more)
was 15 (15%) (Table 1), which is a little bit higher. Previous studies from Thailand reported that
the rate of anti-TB drug induced hepatitis was 9.2% (20) and the rate of NNRTI associated
severe hepatotoxicity was 14% (21). Another study reported that the rate of NNRTI induced severe hepatotoxicity was 20% (7), which is in fact a little bit higher compared to our study (22) .
Many patients 40 (40%) had no significant transaminitis at baseline. This result is lower than
other similar studies (23). However, the prevalence of transaminitis at baseline with toxicity
grade one in our study was 45%, which is a higher compared to other similar studies (23). There
was no Grade four transaminitis occurred in our study (Figure 1, Table 2).
The mean and S.D of ALT at baseline in hepatotoxicity grade zero patients was (33.45, + 17.84).
This result was changed to (38.3, + 21.042) after three months in the same population group. The
mean and S.D of ALT change in heptotoxcity grade one patients at baseline and after three
months were (36.87, + 20.14 and 68.64, + 45.491) respectively (Table 2).
The present study showed that there was no significant correlation in toxicity grade at baseline
ALT measures, (Spearman Correlation Asymp. Sig. (2-sided) = .878). However, the ALT
measure after three month showed that significant association with the grades of toxicity,
(Spearman Correlation Asymp. Sig. (2-sided) = .000) (Table 3).
Table 3: Range, mean and standard deviation of baseline ALT test result compared to after three
months test of patients on anti-TB and HAART medications, Ayder referral hospital, MekelleEthiopia; 2013.
Minimum
Maximum
Mean
Std.
Deviation
ALT baseline
7
91
35.41
19.993
.878*
ALT after 3month
10
301
69.06
61.118
.000*
10 | P a g e
Pearson's R and
Spearman
Correlation Asymp.
Sig. (2-sided)
The prevalence of HBsAg positive serology in our study was 4% (Figure 2), that was lower than
previous conducted study 30 (11.2%) (4). HBV co-infection is a known risk factor for NNRTI
induced hepatotoxicity in HIV infected patients (22). In our study HCV infection was
significantly associated with the risk of hepatotoxicity, which occurred in 3 out of 4 of the study
participants (OR, 22.7; P.value, 0.34) (Table 4) (Figure 2). This figure was lower compared to
other previous studies (7). The difference may be due to the variation in study designs. The
mechanism of liver injury mediated by HBV infection is related to immune restoration after
ART, but the mechanism by which HBV leads to elevated liver enzymes is unclear. It may
induce liver damage by a direct cytotoxic effect or by stimulatnoion of immune response (24).
11 | P a g e
Table 4: Bivariate and multivariate results of binary logistic regression analysis of patient on comedication for HIV/TB infections, Ayder referral hospital, Mekelle-Ethiopia; 2013
41
5
50
Male
11
34
10
35
age
</=18
3
15
4
14
19-62
19
50
10
59
.05
>/=63
3
10
1
12
-.37
HIV
stage
Stage one
1
1
0
2
Stage two
0
1
0
1
-19.62
Stge there
6
29
4
31
Stage four
18
44
11
51
Type
of TB
Pul.TB
8
33
5
36
Extra-Pul. TB
17
42
10
49
ART
reg.
NRTI+NNRTI
25
69
14
80
NRTI +PI
0
5
1
4
.65
NRTI +NRTI
0
1
0
1
.00
TB
drugs
reg.
Cat I
18
67
12
73
Cat II
7
4
2
9
-.58
Cat III
0
4
1
3
HBV
Positive
4
0
3
1
Negative
21
75
12
84
CTM
Yes
22
57
12
67
No
3
18
3
18
Cat=category
12 | P a g e
Reg. =regimen
S.E.
df
No
Wald
14
Yes
Control
Female
Variables
Sex
B
Cases
Hepatotoxicity
.75
.694
Sig.
Exp(B)
1.165
1
.281
.111
2
.946
.879
.004
1
.952
1.054
1.148
.101
1
.750
.694
.628
3
.890
.0004
.000
1
1.000
.000
-20.43
.0004
.000
1
1.000
.000
-.86
1.085
.628
1
.428
.423
-.89
1.046
.737
1
.391
.407
.277
2
.871
1.227
.277
1
.599
1.907
.00057
.000
1
1.000
1.000
.515
2
.773
1.238
.223
1
.637
.558
.82
1.470
.311
1
.577
2.271
3.13
1.476
4.497
1
.034*
22.862
-.497
.781
.404
1
.525
.609
CTM=cotrimoxazole
*=significant
2.116
Figure 2: The prevalence of hepatotoxicity in HBV infected and non infected patients of patients
on anti-TB and HAART medications, Ayder referral hospital, Mekelle-Ethiopia; 2013.
CONCLUSIONS AND RECOMMENDATION
In our study the main factor determining the risk of hepatotoxicity in HIV-TB co-infected
patients apart from the inherent hepatotoxic nature of first line anti-TB and ART medications
was HBV infection. Therefore, we can conclude that HBV co-infection is an independent risk
factor for hepatotoxicity in our study of TB-HIV co-infected patients. Clinicians must therefore
consider the possibility of drug-induced liver injury in the management of HIV-infected patients,
especially those with certain risk factors such as co-infection with hepatitis B virus (HBV) or
hepatitis B virus (HBV).
13 | P a g e
ACRONYMS AND ABBREVIATIONS
AIDS
Acquired Immune Deficiency Syndrome
ALT
Alanine Aminotransferase
ARH
Ayder Referral Hospital
ART
Antiretroviral Therapy
ARV
Antiretroviral
AST
Aaspartate Aminotransferase
CTM
cotrimoxazole
HAART
Highly Active Antiretroviral Therapy
HBV
Hepatitis B Virus
HBsAg
Hepatitis B Surface Antigen
HIV
Human Immune Deficiency Virus
NNRTI
Non-Nucleoside Reverse Transcriptase Inhibitor
NRTI
Nucleoside Reverse Transcriptase Inhibitor
TB
Tuberculosis
ULN
Upper Limit of Normal
ACKNOWLEDGEMENTS
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We would like to thank Mekelle University, College of Health Sciences and department of
pharmacy, and Ayder referral hospital academic, medical and administrative staffs.
DECLARATIONS
Funding: None
Competing interests: None declared
Ethical approval: Not required
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REFERENCES
1.
Pozniak A, Coyne K. British HIV Association guidelines for the treatment of TB/HIV co
infection. British HIV Association HIV Medicine 2011;12:517-24.
2.
Sharma SK, Singla R, Sarda P, Mohan A, Makharia G, Jayaswal A, et al. Safety of 3
Different Reintroduction Regimens of Antituberculosis Drugs after Development of
Antituberculosis Treatment-Induced Hepatotoxicity. Clinical Infectious Diseases.50(6):833-9.
3.
Chu KM, Manzi M, Zuniga I, Biot M, Ford NP, Rasschaert F, et al. Nevirapine- and
efavirenz-associated hepatotoxicity under programmatic conditions in Kenya and Mozambique.
International Journal of STD & AIDS.23(6):403-7.
4.
Wondemagegn Mulu, Bokretsion Gidey, Ambahun Chernet, Genetu Alem, Bayeh Abera.
Hepatotoxicity and Associated Risk Factors in HIV-infected Patients Receiving Antiretroviral
Therapy at Felege Hiwot Referral Hospital, Bahirdar, Ethiopia Ethiop J Health Sci. 2013
23(3):217-26.
5.
National center for HIV/AIDS vh, STD and TB prevention. National center for
HIV/AIDS, viral hepatitis, STD and TB prevention; 2007 [cited 2013 May 27]. Available from:
http://www.cdc.gov/tb/TB_HIV_Drugs.
6.
Y. M. The interaction of HIV and tuberculosis.HIV Prevention Research Unit. Medical
Research Council of South Africa. 2008;3(12): 565-6.
7.
Mankhatitham W, Lueangniyomkul A, W. M. Hepatotoxicity in patients co-infected with
tuberculosis and HIV while receiving Non-Nucleoside Reverse Transcriptase Inhibitor-based
antiretroviral therapy and Rifampicine-containing anti-tuberculosis regimen. Southeast Asian J
Trop Med Public Health. 2011;42(3):651-58.
8.
Price J, C. T. Liver Disease in the HIV–Infected Individual. Clinical Gastroenterology
and Hematology. 2010;8:1002–12.
9.
Lima M, H. M. Hepatotoxicity induced by anti tuberculosis drugs among patients co
infected with HIV and tuberculosis. . Cad Saúde Pública, Rio de Janeiro.28(4):698-708.
10.
Pozniak A, Coyne K, R M. British HIV Association guidelines for the treatment of
TB/HIV co infection. British HIV Association HIV Medicine. British HIV Association HIV
Medicine. 2011;12:517–24.
11.
Mankhatitham W, Lueangniyomkul A, Manosuthi W, Hassen Ali A, Belachew T, Yami
A, et al. Hepatotoxicity in patients co-infected with tuberculosis and HIV-1 while receiving nonnucleoside reverse transcriptase inhibitor-based antiretroviral therapy and rifampicin-containing
anti-tuberculosis regimen. Southeast Asian J Trop Med Public Health. 1371;42(3):651-8.
12.
Nyblom H, Björnsson E, Simrén M AF, Almer S, R O. The AST/ALT ratio as an
indicator of cirrhosis in patients with PBC. Liver Int. 2006;26(7):840-5.
13.
Zechini B, Pasquazzi Z, A. A. Correlation of serum aminotransferase with HCV RNA
levels and histological finding in patients with chronic hepatitis C: The role of serum Aspartate
transaminase in the elevation of disease progression. Eur J Gastroenterol Hepatol 2004;16:91- 6.
14.
Tostmann A, Boeree M, R A. Anti tuberculosis drug-induced Hepatotoxicity. Journal of
Gastroenterology and Hepatology. 2008;23 192–202.
16 | P a g e
15.
W. L. Drug-Induced Hepatotoxicity. The New England Journal of Medicine.
2003;349(5):474-85.
16.
MS S. Drug-induced liver injury associated with antiretroviral therapy that includes HIV1 protease inhibitors. Clin Infect Dis. 2004;38:90–7.
17.
Khadka J, Malla P, Jha SS, SR P. The Study of Drug Induced Hepatotoxicity in Patients
Attending in National Tuberculosis Center in Bhaktapur. Lung DisHIV/AIDS 2009 4(2):17-21.
18.
Shipton LK, Westor CW, Stock S, al. e. Safety and efficacy of nevirapine- and efavirenzbased antiretroviral treatment in adults treated for TB-HIV co-infection in Botswana. Int J
Tuberc Lung Dis. 2009;13:360-6.
19.
Moses M, Zachariah R, Tayler-Smith K, al. e. Outcomes and safety of concomitant nevirapine and rifampicin treatment under programmed condition in Malawi. Int J Tuberc Lung
Dis. 2010;14: 197-202.
20.
Krittiyanant S, Sakulbamrungsil R, Wongwi-watthananukit S, W. S. Risk factors of
antituberculosis drug-induced hepatotoxicity in Thai patients. Thai J Pharm Sci 2002;26( 121-8).
21.
Law WP, Dore GJ, Duncombe CJ. Risk of severe hepatotoxicity associated with antiretroviral therapy in the HIV-NAT Cohort. AIDS Clinical Care. 2003;17:2191-9.
22.
Ena J, Amador C, Benito C, Fenoll V, F. P. Risk and determinants of developing severe
liver toxicity during therapy with nevirapine - and efavirenz- containing regimens in HIVinfected patients. Int JSTD AIDS 2003;14:776-81.
23.
R Kalyesubula, M Kagimu, KC Opio, R Kiguba, CF Semitala, WF Schlech a, et al.
Hepatotoxicity from first line antiretroviral therapy: an experience from a resource limited
setting. Afr Health Sci. 2011;11(1):16-23.
24.
MK. J. Drug-induced liver injury associated with HIV medication. Clin Liver Dis.
2007;11:625-39.
17 | P a g e